Guidance for the Continuous Subcutaneous Infusion of

Syringe Pumps Guidance

Guidance for the Continuous

Subcutaneous Infusion of

Medicines via a Syringe Pump

in Adults


GUIDANCE FOR THE CONTINUOUS SUBCUTANEOUS INFUSION OF MEDICINES VIA A SYRINGE PUMP

IN ADULTS WITHIN THE ACUTE TRUST, COMMUNITY and COMMUNITY HOSPITAL

SETTING WITHIN WORCESTERSHIRE

This validity of this policy is only assured when viewed via the Worcestershire Health and Care NHS Trust website (www.hacw.nhs.uk.). If this document is printed into hard copy or saved to another location, its validity must be checked against the unique identifier number on the internet version. The internet version is the definitive version.

If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on 01905 760020 or email [email protected]

Document Type Clinical Policy

Unique Identifier WAHT-MED-003

Document Purpose To facilitate a countywide approach to managing patients with a continuous subcutaneous infusion of medicines via a syringe pump that promotes a safe and consistent method of practice.

Document Author Amanda Kimpton, Clinical Services Locality Manager R&B & Beryl Taylor, Macmillan Clinical Nurse Specialist

Target Audience Acute Trust Hospital Staff, Community Staff and Community Hospital Staff

Responsible Group Palliative Care Services

Date Ratified 20th April 2015

Expiry Date 20th April 2017

Equality Impact Assessed

6th August 2014

mailto:[email protected]


Key amendments to this guideline

Date Amendment By

Guideline adopted by Worcestershire Acute Hospitals NHS Trust

Accessibility

Interpreting and Translation services are provided for Worcestershire Health and Care NHS Trust including:

Face to face interpreting;

Instant telephone interpreting;

Document translation; and

British Sign Language interpreting.

Please refer to the intranet page: http://nww.hacw.nhs.uk/a-z/services/translation-services/ for full details of the service, how to book and associated costs.

Training and Development

Worcestershire Health and Care NHS Trust recognises the importance of ensuring that its workforce has every opportunity to access relevant training. The Trust is committed to the provision of training and development opportunities that are in support of service needs and meet responsibilities for the provision of mandatory and statutory training.

All staff employed by the Trust are required to attend the mandatory and statutory training that is relevant to their role and to ensure they meet their own continuous professional development.

Version History

Version Circulation Date

Job Title of Person/Name of Group circulated to

Brief Summary of Change

2 July 2014 Macmillan CNS Use of Insuflons for PRNs, References updated

2 July 2014 Palliative Care CNS Use of Insuflons for PRNs, References updated

2 July 2014 Macmillan CNS Use of Insuflons for PRNs, References updated

2 July 2014 Macmillan CNS Uses of Insuflons for PRNs

References updated

2 July 2014 Cluster Lead Use of Insuflons for PRNs, References updated

2 July 2014 District Nurse Use of Insuflons for PRNs, References updated

2 July 2014 Specialist Practitioner Facilitator Use of Insuflons for PRNs, References updated

2 July 2014 Team leader / Palliative Care CNS

Discussion on Insuflons.

General discussion

http://nww.hacw.nhs.uk/a-z/services/translation-services/

http://nww.hacw.nhs.uk/a-z/services/translation-services/


2 July 2014 Community Hospital & Community Palliative Care Teams

Use of Insuflons for PRNs, References updated

2 July 2014 Palliative Care Team - WAHT Insuflons, clarification on training and general discussion

2 July 2014 Consultants Palliative Medicine Comments on Observation charts

2 July 2014 Clinical Managers No comments

2 July 2014 Cluster Leads No comments

2 July 2014 Community Hospital Matrons No comments

2 July 2014 Infection Control Agrees with choice for safer sharps

2 July 2014 Training and Development Manager

Clarity on 2 yearly training & record on esr

2 July 2014 Safeguarding Team Lead Comments added to policy

2 July 2014 Chief Pharmacist Accepts policy


Contents Page 1.0 Introduction 1

2.0 Aim of Guidance 1

3.0 Scope 1/2

4.0 Responsibility 2

5.0 Education and Training 2/3

6.0 The Syringe Pump 3

7.0 Use of Loading/Bolus Doses 4

8.0 Equipment 4

8.1 Choice of Syringe 4/5

9.0 Preparing the Infusion 5/6

10.0 Preparing the Syringe Pump and Syringe 7

10.1 For Two Drugs in the Syringe 7

10.2 For Three Drugs in the Syringe 7/8

10.3 Labelling the Syringe 8

10.4 Battery Power 8

11.0 Fitting the Syringe to the Syringe Pump 8/9/10

12.0 Siting the Infusion 10

12.1 Connecting the SC Infusion Line to the Syringe 11

12.2 Starting the Infusion 11/12

12.3 Keypad Lock 12

12.4 Changing the SC Infusion Line when the patients

medication has been changed 13

12.5 Connecting the SC Infusion Line to a new syringe

when a new SC Infusion Line is required 13

13.0 Care of the Syringe Pump – monitoring the McKinley T34

Syringe Pump whilst in use 14/15

13.1 Care During the Infusion 15

13.2 Stopping the Infusion and Removing the Syringe Pump 15

13.3 How to Temporarily Stop the Infusion 16

13.4 What to do if the Infusion is Interrupted 16/17

13.5 What to do if the patient dies....................................................17

14.0 Cleaning and Decontamination 17

15.0 Syringe Pump Maintenance 17

16.0 Important Notes to Prescribers 17/18

17.0 Documentation 18

17.1 Prescriptions/Directions 18

18.0 The Care Plan held with the patient should contain: 19

19.0 Incident Reporting 19

19.1 What defines an incident? 19


19.2 Safeguarding………………………………………………………20

20.0 References 20

21.0 Useful Links 20

Syringe Pump Chart 21-26

Syringe Pumps Guidance Page 1 of 26

1.0 Introduction Subcutaneous administration of drugs is common and accepted good practice

in palliative care. The syringe pump is a small, portable battery-driven infusion pump used to deliver medication subcutaneously when other routes of drug administration such as oral, buccal, rectal and transdermal are unsuitable.

It is intended that this guidance is used in conjunction with the West Midlands

Palliative Care Physicians (WMPCP) Palliative Care Guidelines for the use of drugs in symptom control 5th Edition 2012, the contents of which should meet the needs of most patients and is accepted as current best practice in the West Midlands Region.

2.0 Aim of Guidance

The aim of this guidance is to assist the practitioner’s decision making whilst caring for patients in the community setting within Worcestershire who require symptom control using drugs delivered by the CME McKinley T34 Syringe Pump. It will also facilitate a countywide approach to managing patients with a syringe pump that promotes a safe and consistent method of practice. The McKinley T34 Syringe Pump has been implemented in Worcestershire in response to the NPSA/2010/RRR019 Rapid Response Report (RRR) issued on 16th December 2010. The RRR identifies that while the majority of syringe drivers and pumps used in healthcare have rate settings in millilitres (ml), some older types of ambulatory syringe drivers have rate settings in millimetres (mm) of syringe plunger travel. This is not intuitive for many users and not easy to check. Errors include the wrong rate of infusion caused by inaccurate measurement of fluid length or miscalculation or incorrect rate setting of the device. Dose errors also occur because of different models using mm per hour or mm per 24 hours. Other issues include syringes becoming dislodged, inadequate device alarms and lack of internal memory (a technical issue which makes establishing the reason for any over or under-infusion difficult).

3.0 Scope

This guidance applies to Registered Medical and Nursing staff working within or on behalf of Worcestershire Health and Care NHS Trust (HACW) who provides palliative care to patients in their own home, Registered Care Homes and Community Hospitals within Worcestershire. The guidance also covers the use of the syringe pump in Worcestershire Acute Hospitals NHS Trust. The CME McKinley T34 syringe pump is a portable, battery operated device for delivering medication by continuous subcutaneous infusion (CSCI). Syringe pumps are a useful way of delivering medication when the oral route cannot be used for a patient and are of particular use in palliative care. If the patient is symptomatic, subcutaneous (SC) bolus dose of medication should be given as the first option for treatment before considering setting up a syringe pump. The McKinley T34 syringe pump is most commonly used to deliver one, two, three or four medicine combinations at a predetermined rate via the SC route over a 24 hour period.


analgesics (usually morphine, diamorphine or oxycodone)

anti-emetics (metoclopramide, cyclizine, haloperidol, levomepromazine)

anxiolytic (midazolam, haloperidol, levomepromazine)

anti-secretory drugs (hyoscine butylbromide, glycopyrronium & hyoscine hydrobromide).

You should consider a CSCI if the patient is unable to manage medication needed for symptom control orally, for example because of:

intractable nausea and vomiting

gastro-intestinal obstruction

dysphagia

head and neck lesions/surgery

severe weakness or unconsciousness

malabsorption

severe stomatitis

unsatisfactory response to oral medicines (uncommon)

patient compliance (also consider transdermal route for analgesia). 4.0 Responsibility

All practitioners who perform this procedure should be aware of the content of this guidance. In addition, all Registered Nurses have an individual responsibility to ensure that they feel confident and competent in the knowledge and skills of practice in line with The Code: Standards for Conduct, Performance and Ethics for Nurses and Midwives (2008). They should inform their immediate line manager if they feel they are not competent and discuss their training needs. Practitioners should also use this guidance in conjunction with the Trust’s Consent Policy when seeking to use a syringe pump with a patient, Infection Control Policy and Procedures, Medicines Policy, Clinical Record Keeping Guidelines, HACW Standard Operating Procedures for Safer use of Injectable Medicines and Health & Safety Regulation (Safer Sharps) 2014. All incidents, including dosing errors etc, should be reported following the HACW Incident Reporting Policy.

5.0 Education and Training

All staff using the McKinley T34 syringe pump must be competent and are accountable in the use and operation of such devices. All managers should ensure that relevant training takes place (e.g. at induction). A record of staff who are trained and competent to use such devices, following face to face essential training, is maintained and recorded (The Management of Infusion Systems, SOHD, 1995).


Worcestershire Health and Care NHS Trust staff

In order for practitioners involved in the setting up and maintaining of treatment via this route to demonstrate the safe and effective use of a syringe pump, education and training that is both theoretical and practical and based on the principles of best practice should be made available. This will be achieved by all staff attending a practical syringe pump workshop provided by the Clinical Nurse Specialists in Palliative Care around the county. This is an essential training requirement for RNs using a syringe pump that should be undertaken every 2 years and recorded on ESR. Worcestershire Acute Hospitals NHS Trust (WAHT) For WAHT staff the Key Trainers in each area will be responsible for training on the device & competencies.

6.0 The syringe pump

If a patient is discharged into the community setting with a different syringe pump in use, the infusion and the device should be removed and replaced with a freshly loaded syringe using the McKinley T34 as soon as possible (within 24 hours). If doses of drugs need to be changed during the course of a 24 hour infusion then once again, remove and replace with a freshly loaded syringe. Never add


medication to an existing syringe or alter the rate of the syringe driver in order to change a drug dose.

7.0 Use of loading/bolus doses

When a continuous subcutaneous infusion of drugs is commenced there is a significant time lag before therapeutic levels are achieved. The need for a separate subcutaneous loading dose of drug(s) should therefore be discussed with the prescriber. A loading dose, administered via subcutaneous route, is specifically indicated if the patient has uncontrolled symptoms at the time of initiating a syringe pump infusion. The prescribing of separate ‘as required’ subcutaneous bolus doses of drugs is also recommended whenever a syringe pump is in use for palliative or terminal care. Never use the syringe driver to administer a loading or bolus dose of drug. NB Registered Nurses must use their professional judgement in choice of device to administer as required medication i.e. for patient comfort and staff safety i.e. insuflon or alternative device. Ideally, changes in drug doses should be made after combined medical and nursing reassessment. Some General Practitioners may, in conjunction with their District Nursing teams, decide to prescribe a dose range to facilitate titration of medication to achieve timely control of symptoms. This dose range should allow for both the reduction and increase of the drug involved as clinically appropriate and should be made clear by the prescriber on the prescription chart.

8.0 Equipment

McKinley T34 syringe pump and plastic lockbox and key

9v battery

Luer-lok syringe (20ml or 30ml may be used)

Infusion or giving set with a volume of 1ml or less (1st McKinley Order code FKA350, 2nd Softset if clinical indication ie emaciated person or infection risk

Clear adhesive film dressing)

Diluent (usually water for injections)

Medication as prescribed. Single use preparations should be used.

Syringe and needles & blind hub to prepare the medicine

Label to be attached to the syringe barrel so that the graduations can still be clearly seen after being completed with the patient’s name, name and dose of drug(s), diluent, final volume (ml), date and time prepared and signature(s) of preparing nurse(s)

Sharps bin

Prescription/Observation chart


8.1 Choice of Syringe

The McKinley T34 syringe pump is calibrated in mls per hour. The standard delivery period for a CSCI in palliative care is 24 hours. It is recommended that only 20ml or 30ml luer-lock syringes are used. It should be noted that different brands of syringes will have different recommended maximum volumes and local guidance should be adhered to at all times. The recommended syringes to use with the McKinley T34 syringe pump are the Becton Dickinson (BD) Plastipak or Braun Omnifix. The most commonly used syringes previously have been 10ml and 20ml, however it has been more recently advocated (Dickman 2007) that a 20ml syringe is the recommended minimum size for several reasons: a larger dilution will reduce both the risks of adverse site reactions and incompatibility and it also accommodates larger doses of drugs. It is therefore recommended that 20ml syringes should be used and that they MUST have a luer lock facility in order to avoid leakage or accidental disconnection. It is therefore recommended that the 20ml syringe is filled to a standardised volume of 17 ml for a 24-hour infusion (Dickman 2007). If a different size syringe is required the fill volumes are recommended as follows:

Size of BD/Braun syringe Fill volume

20ml syringe 17ml

30ml syringe (exceptional circumstances) 22ml

9.0 Preparing the infusion

Refer to Worcestershire Health & Care Trust Standard Operating Procedure for Promoting Safer use of Injectable Medicines for information on preparing the infusion.

Read all the prescription details carefully and confirm that they relate to the patient to be treated.

Check that the prescribed dose has not already been given and that it is appropriate to administer this to the patient under the circumstance.

Check that the time elapsed since any long acting preparations is sufficient.

Ensure that the area in which the medicine is to be prepared is as clean, uncluttered and free from interruption and distraction as possible. This may mean closing doors on family and patients in the patient's home.

Check expiry dates of medications. Check for damage to containers, vials or packaging and for correct storage.

Read all labels carefully since some packaging for drugs are similar except for the drug strength.


Check the patient has no known allergies to the preparations.

Any calculations should be written down in full and a second healthcare professional should independently work the calculation if available or it should be rechecked by the first individual in circumstances where there is no second healthcare professional available.

Prepare the label for the prepared medicine.

Wash hands as per hygiene policy

Dissolve powdered drugs to be used with water for injection using a non-touch technique.

Draw up drugs into the syringe and dilute to the volume required with sterile water for injection if required.

Fit a blind hub if available to the administration syringe and invert the syringe several times to ensure good mixing.

Remove the blind hub. Tap the syringe lightly to aggregate the air bubbles at the needle end. Expel the air and refit the blind hub. Check the syringe for cracks and leaks and then label, applying to barrel of syringe without obscuring calibrations.

Make a note of the volume (ml) in the syringe pump. This may vary with different makes of syringe.

Connect syringe to the infusion line using the luer-lok. The infusion line will need to be primed using some of the contents of the loaded syringe if you are initiating or re-siting the infusion.

Keep ampoules and any unused medicine until syringe driver set-up is complete to enable further checking procedures to be undertaken.

Any unused solutions should be disposed of as per local policy. 10.0 Preparing the syringe pump and syringe

It is considered good practice to make the solution as dilute as possible to reduce the likelihood of drug incompatibility and minimise site irritation.

Remember if the prescription is changed, you must prepare a new syringe. NEVER add an additional medicine to the syringe after the infusion has commenced.

Establish the final volume required and select the appropriate size of syringe

Complete all relevant documentation including a label

Draw up the prescribed medication(s) and compatible diluent [dilute to the maximum volume of the syringe]


10.1 For two drugs in the syringe

Check compatibility

Draw up morphine or reconstituted diamorphine into luer-lock syringe. Then, dilute to an appropriate volume (total volume less than volume of second drug). If neither of the drugs is diamorphine, follow same procedure with alternative opioid, if prescribed, or otherwise with one of prescribed drugs.

Draw up second drug to prescribed dose into a separate syringe of appropriate size and leave needle attached (some vials contain more than the stated dose ie metoclopramide)

Pull back plunger on first syringe to beyond final intended volume, and add second drug carefully through the luer end.

10.2 For three or four drugs in the syringe

Check compatibility

This should be attempted only when evidence of stability exists, or on the advice of a palliative care specialist when other option, e.g. a second syringe pump, is not available or patient is cachectic with few available sites

Proceed in the same manner to above, diluting two of the drugs as far as possible before adding the third or fourth drug.

Draw a little air into the syringe, invert it gently several times to mix the contents, and then expel air, taking care not to expel any of the medication

Attach the completed drug additive label.

The following points should be taken into account when using syringe pumps:

Protect the syringe from direct sunlight whenever possible

Carry out a visual inspection of the solution within the syringe at each monitoring check (at least daily) and discard if evidence of crystallisation, precipitation, cloudiness or change in consistency

Avoid mixing medicines in one syringe if compatibility data is not available; do not mix more than three medicines unless on the advice of a palliative care specialist

Do not infuse the contents of the syringe pump over a period longer than 24 hours

10.3 Labelling the syringe

Ensure the label does not interfere with the mechanism of the syringe pump, i.e. where there is contact with the barrel clamp arm – no part of the label should be underneath the barrel clamp arm. When attaching the label, ensure it does not obscure the visual scales on the syringe which may require to be viewed during the infusion. The following details are required on the label.


patient name

NHS number

medicine name(s)

dose of each medicine

batch number

diluent name

total volume in ml

date and time prepared

initials of the individual preparing the syringe.

10.4 Battery power

Always check the battery power before commencing the infusion. Press the INFO key until the battery level option appears on the screen and then press YES to confirm. The average battery life, commencing at 100%, is approximately 3-4 days depending on use. If the battery power has less than 33% life remaining at the start of an infusion then consideration should be made to discarding the battery and installing a new one (as recommended by McKinley). The battery should be removed from the syringe pump when not in use.

11.0 Fitting the syringe to the syringe pump

Before placing the syringe into the pump, ensure the barrel clamp arm is down then press and hold the ON/OFF key until the `pump identification` screen appears. The identification screen briefly shows the pump model and software version. The LCD display will indicate `Pre-Loading` and the actuator will start to move. Wait until it stops moving and the syringe sensor detection screen (syringe graphic) appears.

During `Pre-Loading` the actuator will return to the start position of the last infusion programmed. If the actuator is not in the correct position to accommodate the syringe, leave the barrel clamp arm down and use the FF or BACK keys on the keypad to move the actuator. Forward movement of the actuator is limited, for safety reasons; therefore repeated depressions of the FF key may be required when moving the actuator forward. Backwards movement is not restricted.


To avoid an inadvertent administration of a bolus dose, the syringe must be attached to the pump before being connected to the patient.

When fitting the syringe to the syringe pump:

Check the patient’s name (and wristband if used) against the prescription, according to the local medication policy

Lift the barrel clamp arm and seat the filled syringe collar/ear and plunger so the back of the collar/ear sits in the central slot (ensure correct placement). The syringe collar/ear should be vertical with the scale on the syringe barrel facing forward

Click the syringe plunger into the actuator. This may require some pressure.

Lower the barrel clamp arm. The syringe graphic on the screen ceases to flash when the syringe is correctly seated at all three points.

The syringe size and brand option will then be displayed as shown below

If the syringe size and brand match the screen message, press the YES key to confirm.

If the syringe size and/or brand do not match, scroll with UP or

DOWN keys until the correct selection appears, then press the YES key to confirm.

Serious incidents have been reported involving uncontrolled flow of medication when the syringe has not been correctly or securely fitted to the syringe pump.


12.0 Siting the infusion

Insert the fine gauge butterfly on the end of the infusion line or Softset into the skin of a convenient subcutaneous site. An angle of 45 degrees to the skin should be used with a butterfly (although this may not be possible in very thin patients) or 90 degrees with a Softset. Loop the line once to reduce traction and secure using a clear adhesive film dressing. The aim is to maintain the site for as long as possible. Softsets should be used only where indicated ie emaciated patients, nickel allergy, infection risk or your professional judgement and are not for standard use. Refer to Health & Safety (Sharp Instruments in Healthcare) Regulation 2013.

Use patient’s preferred site if possible.

Consider siting in the chest or abdomen for ambulant patients

Consider siting in scapula for confused and/or agitated patients

Avoid siting in upper arms for bed-bound patients requiring regular turning but if upper arms are used consider siting in non-dominant arm.

Areas to avoid siting the infusion in:

Inflamed areas Oedematous areas Ascites Broken skin Bony prominences Recently irradiated areas Tumour sites Sites of infection Skin folds Lymphoedema

12.1 Connecting the SC infusion line to the syringe

There are two different situations which can occur:

A new SC infusion line is required because:

o a line is not currently in situ

o the existing line needs to be replaced, e.g. due to site problems or a change in prescribed medication

A line is already in situ and can continue to be used

Shaded areas indicate potential sites


12.2 Starting the infusion

If the patient is symptomatic, a separate as required SC bolus dose of medication should be given at the same time as commencing the syringe pump. Every McKinley T34 syringe pump will be supplied with a lockbox and key. Universal keys are supplied to each ward/community nursing teams. Replacement keys, if required, are the responsibility of individual teams. Lockboxes must be used at all times when the syringe pump is running. If a key is lost it must be reported using the incident reporting system. Place the pump in the lockbox. After confirming the syringe type, the next screen message that appears is displayed below:

Example Figures only The pump calculates and displays the total volume, duration of infusion (24 hours) and rate of infusion (ml per hour). The calculated volume, duration and rate should be checked before pressing YES to confirm or ON/OFF to return to the syringe options.

After pressing YES the next screen message that appears will be:

check the line is connected to the pump and patient

press YES to start infusion

when the syringe pump is running, the green LED indicator (above the ON/OFF switch) flashes and the screen displays


Example Figures only If the infusion has not been started and a button has not been pressed for more than two minutes, an alarm will sound. The message `Pump Paused Too Long` Confirm, Press YES will show on the LCD display. To stop the alarm, press YES and continue programming the infusion.

12.3 Keypad lock

The McKinley T34 syringe pump allows users to lock the operation of the keypad during infusion. The function should be routinely used to prevent tampering with the device. To activate the keypad lock, press and hold the INFO key until a chart is displayed showing a `progress` bar moving from left to right. Hold the key until the bar has moved completely across the screen and a beep is heard to confirm the lock has been activated.

When the keypad is activated the INFO, YES/START and NO/STOP buttons are still active. To deactivate the keypad lock (pump must be infusing) repeat the above procedure. The `progress` bar will now move from right (lock on) to left (lock off) and a beep will be heard. Warning!!! – To reduce the risk of syphonage, the syringe pump should be placed at the same level as, or lower than, the infusion site.

12.4 Changing the SC infusion line when the patient’s medication has been changed

It is considered good practice to change the SC infusion line and use a fresh site when the patient’s prescribed medication has been changed. The need to change the SC infusion line depends on the change in prescription e.g. when a different combination of medicines is prescribed then a fresh SC infusion line should ideally be used. A change of SC infusion line will also depend on the patient’s condition. In cachetic patients and when a syringe pump has been in use over a long period, alternative sites may be very limited. If the existing site is viable and the medicines are compatible, continued use may be in the patient’s best interest.

12.5 Connecting the new SC infusion line to a new syringe when a new SC infusion line is required

When a new SC infusion line is required:


review medication in case cause of problem with infusion line

Attach the SC infusion line to the filled syringe and ensure the luer-lock is fully screwed onto the thread of the syringe tip

Prime the tubing with the syringe pump contents until the fluid just shows at the needle tip.

If a new line is required during an infusion, e.g. due to site irritation, it will require to be primed resulting in the syringe pump not delivering medication over the full 24 hour period. Document the time the cannula and SC infusion line are changed on the monitoring chart. When a new skin site is required e.g. due to inflammation and pain, a new SC infusion line and cannula must also be used.

13.0 Care of the syringe pump - monitoring the McKinley T34 syringe pump

whilst in use

It is recommended best practice, in both the hospital and community setting, when a syringe pump is set-up, reloaded or re-sited to observe the syringe pump during the first 15 minutes to ensure it is functioning correctly. Further monitoring checks should be carried out:

A minimum of 4 hourly within in-patient settings

At each visit by a nurse in the community setting – the frequency of this will depend on factors such as other nursing needs of the patient, the willingness or ability of the patient/carer to assist in monitoring, and the risk of instability of the medicine mixture.

Check the syringe pump and infusion at each visit or 4 hourly in Community Hospitals for:

Irritation at the infusion site – remove, prepare new infusion & resite.

Crystallisation (precipitation) of drugs- seek medical advice.

Light flashing (if not change the battery)

Secure connections &/or no kinked tubing

Leakage

Correct volume remaining

Record on observation chart

The following monitoring checks should be carried out and documented on the Subcutaneous Infusion Monitoring Chart, as follows:

Record the time the syringe pump is checked

Check the infusion site for:

o redness

o swelling

o discomfort/pain

o leakage of fluid

Check the medication is controlling the patient’s symptoms


Check the solution in the syringe and the SC infusion line for cloudiness, presence of large air bubbles (small ones not significant), precipitation or colour change

Record the flow rate and check it is correct

Record the volume of solution to be infused and the volume infused and check from this information that the syringe pump is delivering the medication at the desired rate

Check the battery light is flashing. There is no need to record the battery percentage as this has been carried out already as part of the daily set up.

Record the location of the infusion site when the syringe pump is set up and when the line is changed (this reduces disturbance to the patient during monitoring)

When the infusion site is changed, record the reason in the `Notes` section

At each check inspect the SC infusion line to ensure that it is securely attached to both the syringe and the patient and that it is not leaking, kinked or trapped. If there are any problems, then they must be documented.

The individual carrying out the monitoring checks should document and sign the relevant sections of the monitoring chart. If any checks are not carried out e.g. site check to prevent disturbing the patient whilst asleep, record this and the reason on the monitoring chart. If any checks indicate a problem e.g. the infusion is not running at the expected rate, the appropriate action must be taken and documented in the `Notes` section. If an infusion is discontinued before it is complete e.g. because of a change in dose or medicine, document the amount of solution remaining and destroyed (ml) on the monitoring chart. In the community setting, the patient and/or carer must be given clear guidance on what to do, and who to contact, in the event of a problem arising. Action must be taken and documented in the event of:

Significant discrepancies in the actual and expected infusion rate

Signs of incompatibility

Blockage of the SC infusion line

Damage to the syringe barrel or tip, or the presence of a large amount of air, which may indicate the syringe barrel has cracked

Site reaction

13.1 Care during the infusion

Whilst the syringe pump is in use, the patient and relative/carer should be aware of:

How to take care of the syringe pump e.g. avoid spillages of liquids or dropping the pump and to report if the green light stops flashing or the alarm sounds

Avoiding the use of a mobile telephone within one metre of the syringe pump. Although there are no confirmed reports of mobile


telephones interfering with the operation of the syringe pump, following this advice will help reduce any risk.

Ensuring the syringe pump is well supported when the patient is mobile e.g. placed in a pocket or holster

Who to contact when a problem occurs. Their involvement should be assessed according to individual needs, as not all are able/wish to be involved.

13.2 Stopping the infusion and removing the syringe pump

When the infusion is nearing completion, a warning will be shown on the LCD display screen 15 minutes before the end of the infusion. When the infusion is complete and the syringe is empty, the pump will stop automatically and an alarm will sound. If the syringe pump is no longer required for the patient, press YES to confirm the end of the infusion, disable the keypad lock and press and hold the ON/OFF switch ensuring the pump is switched off. If the infusion is to be stopped before the syringe is empty, it should also be disconnected from the patient for safety reasons. A syringe that is not empty must never be taken off the syringe pump whilst connected to the patient. If the infusion is to be stopped before the syringe is empty, disconnect the pump from the patient before removing the syringe from the pump. Clean the pump and lockbox as detailed under Cleaning and Decontamination on page 17 (do not immerse the syringe pump in water). Dry and replace in packaging if no longer required for use.

13.3 How to temporarily stop the infusion

This is not normal practice and should only be used in exceptional circumstances (this should not be used for priming a second line):

Press STOP, disable the keypad lock and press and hold the ON/OFF button

Do not remove the syringe from the syringe pump

Note the time the syringe pump was stopped on the monitoring chart

13.4 What to do if the infusion is interrupted

To resume the infusion, check the prescription and syringe label match the patient’s details

Press and hold the ON button until a beep is heard

The screen will request confirmation of the syringe size and syringe brand.

If the syringe size and brand match the screen message press the YES key to confirm


If the syringe size and/or brand do not match, scroll down with the up and down arrows until the correct selection appears, then press the YES key to confirm.

The screen message will display:

Press the YES key to resume the previous programme: the screen will display `volume, duration and rate`

Check against the monitoring chart that the duration and rate are correct

Press YES to confirm and the screen will display `Start Infusion?`, press the YES key to confirm

Note the time infusion resumed on monitoring chart.

WARNING – If the NO key is pressed, the syringe pump interprets this as a completely new 24 hour period and the remaining contents of the syringe would be delivered over the next 24 hours from confirming `Start infusion?`. The patient would not therefore receive the prescribed dose. If the NO key has been pressed in error, discard the remainder of the syringe contents and prepare and set up a new syringe.

13.5 What to do if the patient dies when the Syringe Pump is running:

Stop the pump.

Press the “INFO” button and record the date, time and amount of solution remaining to be infused in the syringe (ml). If there are doubts about the circumstances of the death, leave the pump in place and contact your line manager for advice including Safeguarding referral. In a straightforward situation, remove the syringe from the pump, destroy the contents and record the signature(s) of person(s) destroying the remaining solution

Remove the battery from the syringe pump

Remove cannula as soon as possible.

14.0 Cleaning and Decontamination

Carry out cleaning of the syringe pump and lockbox with a damp disposable cloth (use warm water and general purpose detergent). Dry thoroughly. If any additional cleaning is required e.g. contamination with bodily fluids or cleaning the threads of the screws the actuator moves along, contact your local Servicing Department and/or Infection Control Team for advice. Do not use chemicals such as Xylene, acetone/similar solvents or Cliniwipes as this will damage components and labels. Lockboxes should not be cleaned with alcohol-based products as this causes the lockbox to become more brittle.


15.0 Syringe pump maintenance

All syringe pumps must be serviced regularly according to local guidance and at least annually, whether used or not, to ensure their function is maintained. Syringe pumps should be sent for maintenance checks immediately if they have been dropped, suffered fluid ingress (e.g. had fluid spilt over them or dropped in a bath) or if there is any doubt as to their functional operation whilst in use.

16.0 Important notes to prescriber’s

For Worcestershire Acute NHS Trust (WHAT) the Administration of Subcutaneous Drugs via McKinley T34 Syringe Pump and as Required Bolus Drugs Chart is to be completed for discharge only and not used whilst the patient is still an inpatient in WAHT.

The current version of the WMPCP Palliative Care Guidelines for the use of drugs in symptom control (2012) should be kept in the clinical area for staff to refer to and at sites where syringe pumps are used for palliative care therapy. Technical information about compatibility, stability and efficacy of drugs mixed in syringes is available in the guide.

Seek advice from Palliative Care Team if unsure of combinations and / or compatibility of drugs.

Do not leave drugs in a syringe pump for more than 24 hours.

The compatibility of dexamethasone with other drugs is unpredictable and it may be best given in a separate syringe pump or as subcutaneous bolus doses. However, dexamethasone 500micrograms can be added to an infusion to help prevent site irritation, and in this dose is compatible with most drug combinations.

17.0 Documentation

Medication for use in a syringe pump should be clearly written using the documentation specifically dedicated for this purpose and all sections completed (see pages 21-26). *Please note this does not apply for HACW inpatients; the Syringe Pump Observation Chart on page 24 should be used and can be printed from this policy until available in the clinical documents library.

17.1 Prescriptions/Directions

All measurements are in millilitres (ml).

Record / list:

Barcode number on the syringe pump

Date and time

Flow rate in ml per hour

Battery percentage

Diluent name and batch number


Medicine name(s) and batch number(s)

Total volume (ml) medicines and diluent

Site used and appearance

Appearance of solution in syringe (clear, not cloudy)

Signature(s) of person(s) preparing and checking

Note that after commencement of the infusion, all measurements of the volume of solution in the syringe must be accessed via the INFO button.

18.0 The care plan held with the patient should contain:

The indication for the continuous subcutaneous infusion.

An assessment of the efficacy of the drug regimen at each visit.

A record of the indication for and subsequent effect of bolus doses of medication when they have been administered.

A record of the reason for any dose adjustments.

A record of any observed or reported toxicity associated with the infusion e.g. opioid induced hallucinosis and the action and response taken.

A record of batch numbers for Controlled Drugs (CD’s) on chart.

Record syringe pump used on which patient on ELMS 19.0 Incident Reporting

Systems are in place to monitor and report incidents involving syringe pumps and staff should be familiar with the relevant incident reporting system and relevant documentation. All incidents must be investigated. Audit of this information, along with audit against the standards for the use of syringe pumps assists in identifying training needs. Staff to complete a Safeguarding referral for any safeguarding concerns.

19.1 What defines an incident?

When a pump is involved in an incident it should be preserved intact, providing all relevant information to the EBME Department such as operation of the pump that caused harm (adverse event) or could have caused harm (near miss) to the patient or carer. Specific examples include:

Administration of incorrect medication, dose and/or diluent

Infusions completing ahead of intended time (finishing > 1 hour early, assuming a 24 hour infusion, that is approximately 5% or more early)

Infusions carrying on beyond intended time of completion (carrying on for > 1 hour late, assuming a 24 hour infusion, that is approximately 5% or more late – alternatively > 5% of the prescribed medication remaining in the pump at the end of the prescribed infusion period)

Device not alarming during an alarm condition

An error code is being displayed


Please note that where there is a known reason for the infusion not completing on time (e.g. the pump was stopped to enable the patient to bathe; changing the infusion set) then allowance should be given for this delay in deciding whether to report this as an incident.

19.2 Safeguarding

Consider the safe storage of medication in a patient’s home with known drug users.

Remember - Any device and consumable involved in an adverse incident should be `quarantined` i.e. removed from use and sent to the EBME Department immediately. The syringe and SC infusion line should be kept intact with the syringe pump where possible. Where the syringe contains Controlled Drugs (CDs) contact the Pharmacy Department to discuss appropriate action.

20.0 References

CME McKinley Medical UK Limited.

Dickman A (2007) Devices for continuous subcutaneous infusions in Hospital Pharmacy Europe; Technology Update: Syringe Drivers

Nursing and Midwifery Council (2008) The NMC Code of Professional Conduct,

Standards for Conduct, Performance and Ethics. Promoting safer use of injectable medicines (2007) National Patient Safety

Agency. Scottish Office Health Department (May 1995) The Management of Infusion

Systems. West Midlands Palliative Care Physicians (2012) Palliative Care Guidelines for

the use of drugs in symptom control 5th edition Independent Production. Worcestershire HACW (2013) Standard Operating Procedure for promoting

safer use of injectable medicines, prescribing, preparing & administering injectable medicines in clinical areas in the provider services.

Health & Safety (Sharp Instruments in Healthcare) Regulation 2014

21.0 Useful Links

www.palliativedrugs.com

http://www.palliativedrugs.com/







Equality Analysis v1 1st Nov 2012

Equality Analysis

Title of Policy/Function (Function Includes: Services; Projects; Strategy; Processes; Systems;

Practices; Procedures; Protocols; Guidelines; Care Pathways etc..)

New Existing/Revised

Continuous Subcutaneous Infusion of Medications Via a Syringe Pump in Adults

Short description of Policy/Function (aims and objectives, is the policy/function aimed at a particular group if so what is the intended benefit):

For Registered Nurses to deliver medication safely, to those who are unable to take medication by the oral route, to ensure effective symptom control

Name of Lead/Author(s) Job Title Contact details

Beryl Taylor Macmillan Clinical Nurse Specialist (CNS)

01684 612640

When the policy/function involves patients/staff/partners/stakeholders etc please where possible include them in the Equality Analysis to demonstrate openness, transparency and inclusion and particularly by those who this policy/function is most likely to have impact.

Does this Policy/Function have any potential or actual impact that is positive(+), neutral (N) or negative (-) impact on the following protected characteristics please indicate:

+ N - Please provide a rational/justification for each of the following regardless of impact

Age N To anyone ages 18 years & over

Disability

N Would apply to disabled as well as able bodied people. Not aware of any specific disability where alternative arrangements would be made

Gender Reassignment

N Accessible regardless of gender reassignment

Pregnancy & Maternity

+ Would need to consider medication used in pregnancy

Race N Accessible to all races

Religion & Belief

N Accessible to all religions & beliefs acknowledging their beliefs ie reluctance with some analgesia & effect of clouding their mind. Ensure effective communication with all involved

Sex

N This treatment applies to men & women in the same way

Sexual orientation N No bearing on sexual orientation

Marriage & Civil Partnership

N No differences to treatment whether married or single

Other Groups who could experience inequality, eg carers, homeless, travelling communities, unemployed,

people resident within deprived areas, different socio/economic groups eg low income families, asylum seekers/refugees, prisoners, people confined to closed institutions or community offenders, people with different work patterns eg part-time, full-time, job-share, short-term contractors or shift workers - Access, location and choice of venue, timings of events and activities. Support with caring responsibilities None

Equality Analysis v1 1st Nov 2012

Analysis conducted by: (minimum of 3 people)

Name Job Title Contact details

1 Beryl Taylor Macmillan CNS 01684 612640 2 Emma Fisher Palliative Care CNS 01527 488064 3 Carole Robertson

Specialist Practitioner Facilitator

01905 681772

Start date of policy/function July 2014 Period valid for : 3 years

Review date of policy/function July 2017

Service Delivery Unit: Community Reference/Version: ? Date Equality

Analysis completed:

D D M M Y Y 0 6 0 8 1 4

If you have identified a potential discriminatory impact on the policy/function please refer it to the author together with suggestions to avoid or reduce the impact. A copy of the completed Equality Analysis must be attached to the policy/function and a copy sent to: Patrick McCloskey Equality Inclusion Practitioner Isaac Maddox House, Shrub Hill Road, Worcester, WR4 9RW Tel: 01905 761324 [email protected]

mailto:[email protected]

Documents

Guidance for the Continuous Subcutaneous Infusion of